Traumatic (or amputation) neuroma

Abstract

Traumatic (or amputation) neuromaTraumatic (or amputation) neuroma is a rare post-cholecystectomy phenomenon whose pathogenesis remains unknown. Neuromatous change occurs mainly in the cystic duct remnant, 1 with primary gall bladder occurrence highly unusual, having been described only three times in the literature. [2][3][4] The unique operative findings and histology of this case provides new evidence on the aetiology of traumatic neuroma, supporting current theories on its pathogenesis.A 66-year-old man presented with epigastric pain and jaundice. On examination, he was afebrile with mild epigastric tenderness and no palpable masses. Blood tests confirmed obstructive jaundice (normal ranges): bilirubin 191 µ mol/L (3-21 µ mol/L), alkaline phosphatase 132 IU/L (30-120 IU/L), gamma glutamyltrans-peptidase 801 IU/L (10-50 IU/L) and aspartate transaminase 155 IU/L (10-50 IU/L). Full blood count, amylase and electrolytes were normal.Abdominal ultrasound demonstrated a contracted gall bladder containing gallstones. Magnetic resonance cholangio-pancreatography (MRCP) showed three common bile duct (CBD) calculi, with 11-mm CBD dilatation. The gall bladder was not clearly seen. The CBD stones proved difficult to remove during endoscopic retrograde cholangio-pancreatography (ERCP); however, they were successfully extracted after three attempts. The second ERCP was complicated by ascending cholangitis, which responded to i.v. antibiotics.Elective laparoscopic cholecystectomy was performed; however, the procedure was converted to open cholecystectomy because of severe adhesions at the under surface of the liver and between the omentum, transverse colon and abdominal wall. The gall bladder was shrunken and ruptured, having discharged the residual gallstones. Intraoperative cholangiography confirmed the absence of gallstones, and demonstrated moderate CBD dilatation with normal duct anatomy. A fistula was identified between the gall bladder remnant and transverse colon, requiring detachment of the transverse colon and closure of the defect. The gall bladder remnant was excised and the cystic duct closed. The postoperative period was complicated by ileus and wound infection; however, the patient was eventually discharged after 10 days and has been symptom free after 9 months follow up.Macroscopically, the gall bladder wall had marked thickening, up to 10-mm in diameter. Microscopically there were changes of S IMON Fig. 1. Gall bladder microscopy demonstrating pronounced nerve thickening within the muscle layer, consistent with traumatic neuroma.

Traumatic neuroma of the right hepatic duct undertaken right hemihepatectomy

“…It was often the consequence of trauma, surgery, ischaemia or bleeding 2 . The cystic duct region has an abundant supply of nerves, ramifying around it as the choledochal plexus 3 . In the present case, the neuroma was located only in the right hepatic duct rescuing the cystic duct lesion.…”

A late unusual complication after an open cholecystectomy: Amputation neuroma of the CBD causing obstructive jaundice

“…Amputation Neuromas were described at the level of the cystic duct, CBD and CHD [7] . In one case, AN affected the gallbladder, however, there was a history of severe cholecystitis with a cholecysto-colonic fistula [8] . Theoretically, any type of biliary surgery, could lead to an amputation neuroma.…”

“…Amputation Neuroma (AN) is a rare condition that usually occurs following trauma, surgical manipulation or infection of the extra-hepatic biliary tree [1] , [2] , [3] , [4] , [5] , [6] , [7] , [8] , [9] , [10] . In nearly all reported cases, there was a previous history of cholecystectomy [1] , [2] , [3] , [5] , [6] , [7] , [8] , [9] , [10] . In one patient, amputation neuroma developed following bile duct resection for a bismuth type 1 cholangiocarcinoma [6] .…”

“…Amputation neuroma or traumatic neuroma is a benign and rare cause of cholangitis [1] , [2] . It develops usually in patients with a history of surgery to the biliary tract [1] , [2] , [3] , [5] , [6] , [7] , [8] , [9] , [10] . Dealing with this condition is challenging, since preoperative diagnosis remains a difficult task [5] .…”

The Role of Different Methods of Nerve Ablation in Prevention of Neuroma

“…This results from aberrant proliferation of nerve endings in the stump, 1 and may result in neuropathic pain because of persistent abnormal excitability of sensory nerve endings. 2 A number of techniques have been described to reduce the incidence of neuromas in sharply transected nerves.…”